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MRCOG PART 2 SBAs and EMQs

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Essay 304 - Ovarian cyst

Posted by Sophia Y.
Ovarian carcinoma usually presents with non-specific symptoms. Symptoms including weight loss, poor appetite, lethargy and generally unwell may suggest malignancy. I will ask if she has any symptoms of abdominal distention due to the ovarian cyst.
I will ask her last menstrual period as her menstrual status is part of the assessment of risk of malignancy index (RMI). I will ask what contraception and explore her future fertility wishes. I will ask if she is nulliparous by choice or has fertility problem. Nulliparity is a risk factor for ovarian cancer. I will also ask about family history of breast and/or ovarian cancer as they are risk factors for ovarian cancer.

On examination, she might look cachexic. Abdominal distension and ascites may be present. On bimanual examination, right adnexal mass & tenderness may be palpable.

I will check full blood count to exclude anaemia, renal & liver function as part of pre-operative assessment. I will check her CA- 125. The value of CA 125 multiples by 1 (her menstrual state) multiplies by ultrasound score give us the RMI.

I will explain to her that CA125 can be raised in non-malignant conditions such as endometriosis. Nevertheless the combination of large complex ovarian cyst and high CA125 will warrant us to perform a laparotomy for right ovarian cystectomy +/- oopherectomy This allows us to confirm nature of cyst by histology to exclude malignancy. If histology is benign, she should be reassured her fertility is not compromised as long as the left ovary looks normal. However, if histology of ovarian cyst or ovary confirms malignancy, her case will be discussed at the multi-discliplinary meeting with the gynae-oncologists, clinical oncologist, radiologist & specialist nurses about further management. CT scan to exclude distant metastasis. A second laparotomy may be need to remove her left ovary, total abdominal hysterectomy, omentectomy, peritoneal fluid aspiration for cytology for full surgical staging. Her fertility will be compromised.

(b) Discuss the role and limitations of surgical treatment for ovarian cancer [8 marks].

Surgical treatment of ovarian cancer is usually laparotomy, total abdominal hysterectomy, bilateral salpingoopherectomy, omentectomy and peritoneal fluid aspiration. Surgery allows us to remove localised malignant cells, quick symptom relief from the large cyst. It may also allow better effect from chemotherapy treatment. However distant metastasis to eg chest & brain cannot be managed by surgery as it is associated with very high morbidity & mortality. In addition recurrence of ovarian cancer is usually managed by chemotherapy.
Posted by H H.
I would approach the woman in a sympathetic manner as she would be anxious. I would take history regarding her complaint of vague abdominal discomfort,its nature, what increase or decrease it , and if associated with nausea, vomiting, diarrhea, bloody diarrhea , constipation or painful defecation. Would ask of any associated urinary symptoms (dysuria,hematuria, loin pain).Would ask of her LMP ,regularity of cycle,intermenstrual bleeding, postcoital bleed, and her last pap smear if ok.
Would ask of her contraceptive history and if took oral contraceptive pills.Would ask of her fertility wishes and if took fertility treatments.
Would ask of her sexual history and if feel pain during intercourse.
Would ask of any recent weight loss, anorexia, feeling of swelling elsewhere,cough and hemoptysis (symptoms of metastasis).
Would ask of her family history of ovarian , breast or colorectal cancer. Would ask of personal history of breast or colon cancer and treatment given.
Would ask of her social history,her support (family,partner) ,smoking and alcohol intake.
Would tell her about the ultrasound findings , the need to examine her to exclude any spread if it were cancer ,this should be done in a sympathetic manner and do further investigations.
She is told that a blood CA125 will be done and her risk of malignancy measured multiplying criteria seen on ultrasound findings with the level of CA125 by one as she only 37y old. This will give me an idea wether I would refere her to a cancer center for further investigation and treatment, in a multidisciplinary team manner, following guide lines and protocols which are regularly audited in there centers with excellent expertise to give the patient the most optimal therapy.
She is told that a laparotomy would be needed, describe its benfits(staging , treatment) and risks. Describe chemotherapy and that she might need it.Would discus the place of conservative surgery if want children and limitations.
Would give her written information regarding ovarian cancer management and addresses of support groups as cancer association group if prove to be cancer.


B) Surgery in the form of laparotomy is needed for staging and securing a tissue diagnosis, however, intrahepatic metastasis might not be detected and so will need an MRI to exclude them. Surgery in advanced cases may delay the start of chemotherapy.
Primary cytoreductive surgery aim at reducing residual tumour to <1.6 cm3 , as this will improve response and outcome to chemotherapy, however this volume might not be attained.
Surgery in early stages in the form of total abdominal hysterectomy ,bilateral sapingo oophrectomy and omentectomy can be curative and chemotherapy not needed ,however close follow up is essential.
Consevative surgery in the form of unilateral salpingo oophrectomy can be used in stage Ia if this patient wish to have children ,however, there is risk of presence of microscopic cancer in other ovary and need close follow up, further laparotomy might be needed. If complete family ,will need to reoperate to remove uteruss and ovary remaining.
There is no evidence that interval surgery ,after chemotherapy, or second look surgery after 1ry cytoreductive surgery ,have an effect in prolonging patient survival.
Laparoscopy has limited value in ovarian cancer but can be used for tissue diagnosis and staging, however its use limited by inherent risk of visceral injury.
Palliative surgery in the form of nephrostomy or colostomy can be used in advanced stages to relief obstruction ,with no effect on prognosis.

Posted by Johnson  O.
A/
I will inform her the findings in a sensitive way, knowing it may generate anxiety. Detailed history including age at menarche, last menstrual period, regular or irregular period, heavy menstrual bleeding. History of painful period, dyspareunia and chronic pelvic pain which may be suggestive of endometriosis. I will ask about type of contraception she is using orshe has been trying for pregnancy. I will ask about her desire to preserve fertility, because this will be a factor in her management. History of weight loss to exclude malignancy. Rectal bleeding, haematuria, or haemoptysis to exclude possibility of metastasis or endometriosis.
Family history of ovarian or breast cancer and personal history of breast cancer, this increases her risk of ovarain cancer.
Examination will include her BMI, abdominal distension, palpate for size, soft or solid mass.Examination of the vagina, any cervical mass. Bimanual palpation for palpable adnexial mass, fixed or mobile uterus and if the mass is separated from the uterus.
I will inform her that most ovarian cyst in her age group are benign, in the absence of personal and family history. However, we need to do investigation to assess risk of malignancy and offer appropriate treatment. Risk of Malignacy index[RMI] involve ultrasound scan findings and Blood CA125 which is a marker for ovarian cancer. There are other condition that can raise the level of CA125 like endometriosis. If the RMI is above the cut off of 250 she will be managed at cancer centre by staging laparatomy. If the risk low, cystectomy by laparatomy or laparascopy will be offered
Information leaflet about ovarian cyst will be provided to her. She will also be given contact details of the hospital.
B/
Surgical treatment of ovarian cancer depends on the stage of the malignancy, her desire to preserve fertility and her wishes.
Surgical treatment remove the tumour and therefore may be curative in early stages. It play role in providing tissue for pathology and definitive diagnosis.
Staging laparatomy provide an opportunity to assess the extension of the disease, this help to determine if chemo or radiotherapy will be required.
Many Ovarain cancer present in advanced stage.Surgical treatment has limitation in advanced cancer which may be inoperable. In this case palliative care, chemo or radiotherapy will be more appropriate.
If she desire to preserve fertility, then there is limitation to surgical treatment. It may have to be limited to oophorectomy on the disease ovary with consevation of uterus and other ovary.
Aspiration of the cyst for cytology has poor sensitivity and specificity and is not recommended. There is also increase risk of spillage into peritoneal cavity causing spread of the disease.
Availability of expertise to do the procedure, therefore it should be done at cancer centre. Woman wishes not to have surgery is also a limiting factor.
Posted by C P.
A healthy 37 year old nulliparous woman has been referred to the gynaecology clinic with a 6 months history of vague abdominal discomfort and an ultrasound scan showing a 10cm complex right ovarian cyst. (a) Discuss your initial assessment including how you would counsel the patient [12 marks]. (b) Discuss the role and limitations of surgical treatment for ovarian cancer [8 marks

C
In the history I would ask her about the nature of the pain and radiation of the pain. What factors relieves the pain. Any pressure symptoms to the bladder or bowel need evaluating. Did she feel the mass in the abdomen, if so does she notice that the lump is increasing in size over the time.
Her fertility issues need exploring because some time fertility preserving surgery need to be done. I.
Her appetite and any history of loosing weight should be finding out. In malignancy normally appetite will be poor and she would have lost weight.
I will enquire about her personal or family history of breast cancer or ovarian cancer. If her family history suggestive of breast or ovarian cancer I will try to find out BRACA mutation status. If present this carries risk of ovarian cancer.
Age of menarche, use of contraceptive pills are essential to asses the risk of ovarian cancer. Late menarche and use of contraceptive pills will reduce the risk of ovarian cancer.
In the examination I will look for loss of weight will suggest chronic illness. During per abdominal and vaginal examination I will look for consistency of the lump, whether it is freely mobile, and the size of the uterus. If she has any chest symptoms I will do auscultation of her lungs.
I will do CA 125, in epithelial cancer it will be raised. In reproductive age group CA125 can be raised in endometriosis and PID. Because of the nature of complexity I will organise MRI to know the extent of the lesion. If she is anaemic or any infective cause FBC will give some idea about it. If patient is severely anaemic she will be needing blood transfusion. If any surgery imminent obviously I will organise some blood to be group and save. U/E and LFT are essential they need to be assed prior to the surgery and chemotherapy. Chest X ray for any suspicion of secondaries in the lung or if she has any respiratory symptoms.
I will asses her RMI. This will make a suggestion where she should be operated. RMI over 250 should be operated in the cancer centre to improve her five year survival.
In the counselling I will tell her complexity of the cyst may be due to benign or it can be ovarian cancer. If it is a benign she will need only oopherectomy and her fertility will be retained. If it is a cancer she may require extensive surgery where she will loose her fertility depends upon the stage of the diseace.

Since there is no screening programme to detect ovarian cancer most of the time it is diagnosed very late stage. Mostly the surgery is done for staging.
In 1A, unilateral oopherectomy can be done and wait until the patient could finish her family. If 1B she will need bi lateral oopherectomy. Anything beyond this she will be needing hysterectomy and bilateral sulpingo oopherectomy and omentectomy.
De bulking surgery is done to reduce the bulk of the cancer to increase the affect of chemotherapy. Also debulking improves the patient’s psychological aspect and her symptoms of her bowel as well as her bladder. In some cases where the de bulking is not possible, chemotherapy can be initiated first and later de bulking can be done.
In a very late stage of the disease some time where curative is not possible palliative surgery will be performed to improve her quality of life and relieve her symptoms
Posted by Manoj M.
M
(a) This patient is likely to very anxious in the clinic with the scan diagnosis. A history of associated bowel and bladder symptoms like contipation or urinary obstruction may suggest possibility of underlying malignancy. A history of deep dysparenuia or dysmenorhoea may suggest possiblity of endometriosis.
Her fertility choices should be obtained as she may need fertility sparing procedures for her treatment. Her detailed menstrual history including menarche, her current cycle history to ascertain her risk and also to exclude ovarian dysfunction. A history of loss of appetite and loss of weight may suggest possibility of underlying malignancy. A family history of breast cancer, ovarian cancer or colonic cancer may increase her risk for underlying malignancy. Respiratory symptoms like breathless or neurological symptoms like weakness may suggest distant metastasis.
Examination should include her pulse , BP, BMI assessment as she will need a surgery in the immediate future. Abdominal examination to assess the consistency of the cyst and also to exclude clinical ascitis, bimanual examination to ascertain the consistency of cyst, mobility of cyst and to define if uterus is involved with the cyst or seperate so as to decide her treatment options. Respiratory and neurological assessment as directed from history.
Counselling should be non directive by a gynaecologist with her wishes considered including her fertility options. This depends upon RMI calculated with CA125 done. If RMI is <200 risk of malignancy is lower and she will be offered surgery in the cancer unit and options for fertility sparing procedure and more likely to be curative. If RMI >200, risk of malignancy is increased and she will be offered treatment after gynaecology oncology MDT and treatment offered at cancer centre, this may involve pelvic clearance and and may need further treatment like chemotherapy depending on histopathological diagnosis and staging of the disease. If it is benign cyst she may need only one surgery and curative and may not need any further followup or treatment, however if malignant she may need further treatment and followup as risk of recurrance. If diagnosed with endometrioma after removal of cyst she may need further medical or surgical treatment with risk recurrant disease.

(b) Role of surgery will include specimen for diagnosis and removal of cyst may be curative. Surgery will provide surgical staging with underlying malignancy and option for pelvic clearance. Role of surgery will also help in diagnosisng underlying pelvic endometriosis and removal of endometrioma which may help in improving fertility rates.
Limitation of laparoscopic surgery include difficulty in removing the cyst intact with a 10cms cyst and risk of spillage with risk of upstaging with underlying malignancy, this can be reduced using cyst aspiration in enclosed bags like spleen bags and then removal of the cyst wall. Laparoscopic expertise is not easily available in all centres and may need expensive instruments for these procedures and may not be cost effective.
Limitation of Laparotomy include bigger abdominal incision but possible to remove cyst intact with minimal risk of spillage, also with increased recovery time for the patient compared to laparoscopy.
Removal of cyst alone may warrant second laparotomy if histopathology diagnosis of malignancy. Cyst aspiration alone is not beneficial in confirmation of cytological diagnosis and not recommended and with dermoid cyst spillage associated with risk of chemical peritonitis.
Surgery may not be curative with underlying malignancy and may need further treatment including chemotherapy of palliative care.
Posted by laura H.
I would take full gynaecological history and particularly I would ask if her complain associated with any other symptoms or changes such as menstrual irregularity, dysparunia or pelvic pain may suggest endometriosis. Menstrual irregularity can be also due to granulose cell tumour and determine her menopausal state. I will also look for red flag symptoms, any loss of weight, haematuria or recent vaginal or rectal bleeding that may indicate malignancy or hirsutsim or breast atrophy that indicates virilisum (arrhenoblastoma). I would enquire about type of contraceptive she uses as progestogen only contraceptive has increase incidence of ovarian cysts, whether she if subfertile or had hormonal ovulation before. I would also ask whether she is on HRT due to any gynaecological causes which increase risk of ovarian cancer for current and recent users’ tumour.
I would her personal and family history (maternal and paternal)of ovarian, breast cancer, endometrial cancer, prostate or colorectal cancer particularly for first degree relatives, or clustering of these tumours in the family or occurring in young person. I would also ask if she is known carrier for BRCA1, BRCA2 or mess mach repair genes (HNPCC).
On examination I would do complete general examination and take verbal consent to examine her breast look for lump, abnormal discharge. I would do lymph node examination, particularly supraclavicular, subaxilary and inguinal. I would also offer her abdominal & pelvic examination, to look for ascitis, any sign of virilism and I would examine vagina and cervix for any visible endometriosis, tenderness and nodularity in pouch of Douglas or uterosacral ligament. I would examine gently the cyst mobility and also relation and adherent to other structure such uterus.
I would request FBC and CA125, LDH, PLAP, CEA, AFP, inhibin and esradiol. I would review the detail of ultrasound report to use it with her CA125 if raised to calculate Risk of Malignancy Index, which I would use it to place and proper management plan and counsel her regarding possible risk of malignancy and ensure that understand that this is not diagnostic test. I would also reassure the women that most of ovarian cysts in reproductive age are functional and most of ovarian tumours are benign with less than 10% of of epithelial tumour are malignant. Most of ovarian malignancies in reproductive age are relatively having good prognosis such as early epithelial cancer, borderline tumour and germ cell tumour.
b) The main role of surgery is diagnostic, staging and curative. For early sages’ epithelial ovarian cancer full surgical staging through midline extended vertical incision involving cytology of ascitis or washing, total abdominal hysterectomy bilateral salpingo- oophorectomy infracoloic omenectomy, biopsy from suspicious lesions. With optimal cytoreductive that means no nodules more than 1 cm left in situ as this will improve response to chemotherapy in early stage epithelial ovarian caner. In advanced cancer the treatment is maximal primary cytoreduction with selective para aortic and pelvic L.N, although this will increase morbidity
It is important that cyst not ruptured or aspirated as that will worse the prognosis. In postmenopausal no place for cystectomy women will be offered bilateral oophrectomy. In woman with apparently less risk of malignancy laparoscopic surgery can be an option provided full staging is carried out, and full lapratomy is required if malignancy was visible on laparoscopy. However there is 1-20% risk of port metastases with laparoscopic surgery and also there is concern of increase ovarian cancer growth with exposure to co2 in vitro. In woman with stage 1 borderline, early epithelial ovarian cancer (1a&1b grade 1) surgery is the only required treatment and fertility sparing surgery is an option. Woman with germ cell tumour the main surgical approach is minimal cytoreduction with conservation of fertility.
Surgery has no role in recurrent epithelial ovarian cancer. However is still main option for recurrent both germ cell and sex cord tumour.

Posted by Bee N.
A) The diagnosis of ovarian cyst often generates anxiety and I will try to calm the patient explaining that most ovarian cysts in women within her age group are benign and most complex cysts within this age group atre either dermoid or endometrioma. I will ask about history of weight loss and anorexia which are pointers to malignancy. I will ask about pressure symptoms such as constipation and frequency or incontinence of micturition to establish severity of disease. I will also ask about hematuria, maleana, coughing which may indicate metastasis. I will ask about her contraceptive history as this is a protective factor to ovarian cancer. I will enquire about her fertility wishes as this may influence management. I will enquire about mentrual history to make sure that she is not post menopausal and to ascertain if there has been recent changes which may be secondary to estrogen producing tumour. I will ask if she has any family history of breast, ovarian or endometrial cancer which increases her risk of malignancy. I will enquire about her medical history to konw how suitable she would be for surgery. I will also ask about her smear test history as this may be an opportunity to take one.

I will then examine this patient, paying particular attention to her BMI which would assess her suitability for sugery. An abdominal examination to elucidate tenderness or other masses or ascitis. A vaginal exam would reveal how fixed to pelvic strutures the right ovary is and how tender it is.

Investigation will start with a urine pregnancy test if this is possible. This is to make sure I will not be operating on a patient in early pregnancy. I will then perform a full blood count, liver function test and electrolyte and urea in preparation for surgery. Some of the values may be deranged in ureteric obstruction or metastatic disease. I will perform a CA-125 and calculate her Risk of Malignancy Index (RMI) to decide where she should be managed. I will inform her CA-125 only screens for epithelial ovarian cancer and there can be false positive results of CA-125 e.g pregnancy, endometriosis, fibroids. I will also tell her the CA-125 is only raised in 50% of those with stage 1 epithelial ovarian cancer. the only confirmatory test for cancer in a biopsy of the tumour. If her RMI is morderate or high, I will discuss her further management in a multidisciplinary meeting.Her consent will be taken before any planned surgery. If RMI low, she can have a laparotomy where cystectomy can be done if diagnosis of dermoid cyst is obvious. If in any doubt, right ovarian oophorectomy will be done. She will be informed that this will preserve her fertilty as long as the second ovary is normal.Further management will depend on histology report. This may require further multidisciplinary discussions, total abdominal hysterectomy, omentectomy and peritoneal washing in a second laparotomy depending on patients wishes and consent.


B) In the treatment of ovarian cancer, surgery can be curative if very early stage disease such as stage 1. Surgery also enables biopsy for confirmation of diagnosis. Samples taken dfrom other tissues like the omentum and ascitic fluid also helps in staging of the disease. Pressure symptoms can be relieved by removal of huge ovarian cyst. Other palliative surgeries such as colostomy and nephrostomy can be undertaken by surgery.
Most cases of ovarian cancers are however discovered late and surgery then will not be curative. As a matter of fact surgery is of no proven benefit in very late stage disease as the life expectancy is not improved. Advanced diseases may neeed the presence of colorectal surgeons and urologist in a combined surgical team.Surgery is associated with complications and increased post op morbidity. Patients with high RMI will need to be referred to cancer centres the absence of which may delay surgery.The risk of thrombo embolism which is high in cancers is further increased by surgery. The patient pre morbid condition vis a vis medical history may limit possiblity of undergoing surgery as patient may pose an anaesthetic risk.
Posted by Mohamed A.
a)

I will enquire about menstrual history: early menarche is a risk for ovarian malignancy, irregularities, menorrhagia or intermenstrual bleeding may point to hormone producing tumours, contraceptive history and duration COCPs might be protective while BTL may increase risk , pain associated with menstruation, dyspareunia may suggest an ovarian endometrioma. History of fertility treatment and fertility wishes should be put inconsideration.

Associated bowel symptoms should be asked for; bloating, early satiety, constipation and loss of appetite. Patients with ovarian carcinoma frequently present with vague gastrointestinal symptoms but also may suggest primary GI malignancy. Pressure symptoms as frequency, constipation and pelvic pain.

History of STD’s and PID for the possibility of tubo-ovarian abscess.

I will ask about recent weight loss and family history of breast, ovarian or colorectal cancers.

General well being, cachexia, weight and BMI should be checked. Breast should be palpated and lymph nodes sought in the neck, supraclav. Axillae and groin. Abdomen examination for male hair pattern if androgen producing tumour, dilated veins, palpated for liver, tenderness, any palpable masses and shifting dullness for ascites.

Bimanual examination and rectovaginal examinataion for mobility, texture, consistency, tenderness and nodules in D. pouch.

Investigations done to assess likelihood of malignancy, assess fitness for surgery and plan extent of surgery. FBC, group and save, renal and liver function tests as apart of preoperative assessment.

Tumour markers should be measured, mainly CA-125 which is elevated in 80 percent of all patients with serous cystadenocarcinoma of the ovary, however raised in endometriosis and PID. other tumour markers AFP, hCG and lactate dehydrogenase due to relative increased risk of germ cell tumours at this age. CEA may identify primary GI malignancy.

Chest X-ray help to identify effusion or metastasis, MRI and CT abdomen and pelvis required to detect and exclude intra-hepatic disease and distant metastases which might not be detectable at laparotomy.
.
Risk of malignancy index being the product of serum CA-125, ultrasound score and menopausal state should be assessed, refer to cancer unit if level 25-250 and refer to cancer centre if >250.

I will tell her that the findings are suggestive of ovarian tumour, likely to be malignant, chances to be border line or malignant is 1 in 10. However confirmation will only available after histological examination. An operation involving abdominal incision should be performed involving unilateral oophorectomy with surgical staging and describe the procedure.

Good chance of cure if ovarian malignancy is diagnosed and treated at an early stage (5 years survival for stage Ia-Ib approx. 90%)

I will tell her that fertility may be preserved if unilateral oophoretomy is adequate treatment and ovarian tissue can be stored.

She should be informed that she might need an adjuvant treatment (chemotherapy or second look laparotomy after histological results) and follow up is required.

She should be offered written information and consent obtained for surgery.

b)

Staging laparotomy useful in confirming diagnosis, influences subsequent treatment, enables prognosis to be determined and provides data for research and potentially curative in early disease (stage IA)

The value of laparoscopic surgery for ovarian cancer is unproven.

Conservative surgery helps to maintain fertility in early stage disease (stage I, grade I) with possibility of storing ovarian tissue for future fertility. However risk of tumour in conserved ovary not detected at the time of surgery thus close follow-up therefore required. And second laparotomy may be required if histology shows more advanced or high grade tumour

Primary cytoreductive surgery improves response to chemotherapy, treat complications caused by tumour as pressure,ascites and provide psychological benefit, however, associated with surgical morbidity and may delay onset of chemotherapy with little potential benefit in circumstances where the tumour is inoperable and value in improving survival unproven.

Second look procedures (laparotomy or laparoscopy) controversial and value unproven. Interval surgery after chemotherapy and secondary cytoreductive surgery after recurrence are also of unproven benefit.


Posted by Akanksha G.
A healthy 37 year old nulliparous woman has been referred to the gynaecology clinic with a 6 months history of vague abdominal discomfort and an ultrasound scan showing a 10cm complex right ovarian cyst. (a) Discuss your initial assessment including how you would counsel the patient [12 mark]
my initial assessment would include, enquiring of symtoms suggestive of possible metastasis like altered bowel habits(diarrhoea, constipation, blood in stools, tenesmus) altered bladder habits (like hematuria) a family history of ovarian, breast, colon cancer in first or second degree relatives. since she is a nulliparous women i would enquire her desire for fertility would would be taken into account in deciding the type of surgery. in examination i would look for organ enlargement (liver), presence of ascitis, a pelvic examination to know whether the cyst is fixed or mobile, unlateral /bilateral. i would investigate for tumor markers like CA125,( marker for non mucinous tumors of ovary) and AFP, HCG if germ cell tumor is suspected. i would review the ultrasound report looking for specific details like presence of ascitis, evidence of metastasis, solid areas in the cyct, multiloculation. i would then calculate the risk of malignancy index(RMI) using the formula for RMI 2(with a sensitivity of 80% specificity of 90%) i.e. menopausal statusX ultrasound markers scoreX CA125 levels(in U/ml) a value of >200 indicates a high risk for cancer and would consider referring the women to a cancer specialist. my counselling of the women would include providing both verbal and written information about the disease. i would counsel her that she would require surgery for removal of the cyst, the extent of the surgery would depend on intraoperative findings. if the capsule of the cyst is intact and no peritoneal disease a frozen section of the tumour, and peritoneal fluid cytology would be done if on frozen section the tumor is found to be benign a simple cystectomy would be sufficient. if it is found to be malignant and confined to the ovary a fertility sparing surgeyr may be possible with retaining the contralateral ovary and the uterus however there is 9% chance of recurrance. however with more advanced disease findings she would require extensive surgery with removal of both the ovaries and uterus. the requirement for further chemotherapy would depend on the extent of the disease and the histological type.
Discuss the role and limitations of surgical treatment for ovarian cancer [8 marks].
primary surgery is the treatment of choice for early ovarian cancer and is the usual first line for advanced ovarian cancer. sugery alone is sufficient for patients with figo stage 1a and 1b unless additional risk factors (intraop rupture of capsule, clear cell histology, grade 3 tumors) are present. in advanced ovarian cancer surgery can be either aggressive cyto reduction where all the disease has been removed where possible or can be optimal cytoreduction where residual tumor is no more than 2 cm. many a times interval debulking surgery may be done . this involves a secondary surgery after 3 courses of chemotherapy where in optimal cytoreduction was not posssible at primary surgery. surgery may also be considered in bowel obstruction secondary to the tumour. limitations of surgery are it carries high morbidity especially in the post menopausal women. adaquete antibiotic coverage and throbopeophylaxis is required. optimal cytoreduction may not be posssible always such as when the tumour is located adjacent to major vessels. even after complete removal of both the ovaries primary peritonal recurrences are possible.
Posted by A A.
Further assessment of this women is required to find out whether the mass is benign or malignant. I will ask about the severity and nature of symptoms.Regarding GIT symptoms, abdominal bloating, distension,loss of appetite,weight change and altered bowel habits like constipation is more in favour of neoplasm.Symptoms of mass effect like urinary frequency, urgency and incomplete emptying.I will ask her LMP,regularity of cycle,cycle length,menorrhagia and IMB/PCB.HIstory of abnormal vaginal bleeding in presence of mass is more in favour ofneoplasm.I will ask about chronic pelvic pain,dysmenorrhoea and dyspareunia that might suggest endometriosis.I will askabout last PAPs smear report.Contraceptive history like use of COCP. History of infertility,any treatment taken and future fertility wishes to be taken into account during treatment. Personal / family history of breast, ovarian cancer or colon cancer.A positive history will raises suspicion of malignancy.I will ask about social history regarding local support.I will do her general physical examination.In abdominal examination, presence of ascites,irregular,hard and fixed mass will be more in favour of malignancy while regular,firm and mobile mass is more in favour of benign tumour. I will also check for any other organomegly like liver.IN pelvic examination I will inspect vulva and vagina and bimanual examination for uterus,whether it is separated from the mass,bulky and both adenexae for masses. In investigations I will send FBC, tumour markers like CA125(epithelial tumour),HCG and AFP for germ cell tumour.A detailed USG examination to calculate risk of malignancy index which is the product of woman’s premenopausal status X CA125 X USG features. If the RMI is > 200 there are more chances of malignant disease and CT of abdomen, pelvis and chest will also be advised to find the extent of disease.
I will explain the diagnosis to the woman that she has a ovarian cyst which is not simple, it could either be benign or malignant so further investigation is required. This would be likely to create an anxiety and stress so the approach to the woman will be sensitive,supportive and empathic.IF findings are suggestive of benign disease there will be a need to remove cyst or ovary via surgery(laparotomy)and no further follow up will be required.BUT If the features will be suggestive of a malignant disease she will need to be be referred to the cancer centre where specialist expertise are available and her case will be discussed in the regional MDT meeting. For definitive diagnosis surgery and tissue sampling for histopathology is required. Surgery will include midline incision and exploration of abdomen and pelvis and management depends upon her desire for fertility, stage of the disease and type of tumour. In the early stage disease (1a)fertility conserving surgery.But there will be chances of recurrence and if histology report shows a high grade or advanced stage disease reoperation will be required and prolonged follow up will be required. Prognosis and 5 year survival is dependant upon stage and histopathology and type of tumour. It will be good in early stage epithelial ovarian cancer, germ cell tumour and border line tumour.
Part B) Staging laparotomy is the main stay of treatment.It provides opportunity to assess the disease directly and confirm the diagnosis.It influences the subsequent management (like chemotherapy, further surgery in case of conservation). It also enables to determine the prognosis of disease and provides the data for research. However it cannot detect the microscopic invasion and distant metastases for which CT/MRI is required. As a CURATIVE SURGERY it has a role in stage 1a disease but careful follow up will be required. It also has a role as a CONSERVATIVE SURGERY for fertility in early stage disease (1a) in women who wish to retain their fertility. In which case unilateral salpingoophrectomy and omentectomy is done but there is a risk of undetectable tumour in conserved ovary or a new tumour (risk of reccurence).So careful and prolonged follow up is needed. If histology report show high grade or advanced disease repeat surgery will be required. It has a role in advanced disease as PRIMARY CYTOREDUCTIVE SURGERY. One approach is optimal cytoreduction with the aim of leaving residual disease of no more > than 2 CM. It will result in improved response to chemotherapy and relieve the symptoms like bowel obstruction, ascites and pressure effects.IT aiso provides psychological benefits but can delay treatment with chemotherapy.Other approach is aggressive cytoreductive surgery with the aim of leaving no residual tumour,but it is not possible in all cases and is associated with increasedmorbidity.INTERVAL DEBULKING SURGERY has a role in terms of survival benefit if primary surgery is not performed by gynaecological oncologist and and there is a response after 3-4 cycles of chemotherapy as shown by imaging and CA125 levels. Role of 2nd look laparotomy and secondary cytoreductive surgery in case of recurrence is unproven in terms of survival benefit. In advanced disease surgery has a role for palliative purpose.
Posted by Asa A.

Asa
a) . I will ask about family history of breast or ovarian cancer and at what age it was discovered . I will ask about other symptoms like weight loss , abdominal distention and breathlessness .I will ask about intentions of having children in the future .I will see if she looks cachixic . I will examine her abdominally for acsites . Bimanual pelvic examination of the mass , fixed or mobile and relation to the uterus .
I will explain the findings of the ultrasound to the patient that there is a mass on the right side the cause of which can t be decided by u/s . There is a possibility of cancer and we need further tests and imaging to discover the extent of the disease. She will need surgery to remove the mass and verify the diagnosis.The surgery must be done by gynecological oncologist . I will tell her that if the mass is benign she will not need any further action but if it is cancer the surgery will include removal of both ovaries , the uterus ,the omentum and sample of any fluid in the abdomen for cytology. Surgery sometimes may be difficult and the surgeon may not be able to remove the whole tumour . She may need chemotherapy post operative depending on the finding during surgery and disease stage .The prognosis depends on the type and stage of the disease . The implication of this is that she will not be able to have any children and will enter into menopause. If she would opt for conservative surgery to preserve fertility , the risk of recurrence will be high . She can use HRT after surgery to protect her bones from developing osteoporosis . On the other hand HRT may increase the chances of cardiovascular disease or cancer breast although this is not proven for premature menopause . Trying to reserve part of the ovary or to save eggs is not applicable now . She will be given written information and addresses of support groups . I will inform her about the ongoing clinical trials for ovarian cancer .
I will do FBC ,LFT , urea & electrolytes .Tumour markers CA125 to calculate RMI ( u/s criteria multip ca125 multip 1) and CEA will be done . Abdominal u/s and CT abdomen nd pelvis will be done to discover ascites or liver or other organ metastasis and to examine any lymph node enlargement . IVP will be done to see the ureter and its relation to the mass .
b)Surgical treatment is the cornerstone for management of ovarian cancer . Primary debulking surgery for stage 1 and 2 with aim of cure will include removal of the tumour , total hysterectomy ,bilateral salpingooopharectomy , infracolic omentectomy and peritoneal wash for cytology . It includes also tissue biopsy from the under surface of the diaphragm and pelvic & paraortic lymph node biopsies .The prognosis is best if the operation is done by gynecological oncologist in a multidisciplinary center .
Fertility reserving surgery done in young women as cystectomy or oopharectomy (less than 40 ) for stage 1 disease have a recurrence rate of about 9% .
In advanced disease where traement is palliative (stage 3& 4) debulking surgery aims to reduce the residual tumour mass to less than 2 cm . Interval debulking surgery could be done if response to chemotherapy as judged by imaging and CA125 is not optimum . The effect of this surgery on survival is uncertain .
Surgery has a role in recurrent disease .Secondary debulking surgery may be done . However this must balanced against morbidties like bowel obstruction and adhesions and ending with colostomy and quality of life of the patient .



Posted by Asa A.

Asa
a) . I will ask about family history of breast or ovarian cancer and at what age it was discovered . I will ask about other symptoms like weight loss , abdominal distention and breathlessness .I will ask about intentions of having children in the future .I will see if she looks cachixic . I will examine her abdominally for acsites . Bimanual pelvic examination of the mass , fixed or mobile and relation to the uterus .
I will explain the findings of the ultrasound to the patient that there is a mass on the right side the cause of which can t be decided by u/s . There is a possibility of cancer and we need further tests and imaging to discover the extent of the disease. She will need surgery to remove the mass and verify the diagnosis.The surgery must be done by gynecological oncologist . I will tell her that if the mass is benign she will not need any further action but if it is cancer the surgery will include removal of both ovaries , the uterus ,the omentum and sample of any fluid in the abdomen for cytology. Surgery sometimes may be difficult and the surgeon may not be able to remove the whole tumour . She may need chemotherapy post operative depending on the finding during surgery and disease stage .The prognosis depends on the type and stage of the disease . The implication of this is that she will not be able to have any children and will enter into menopause. If she would opt for conservative surgery to preserve fertility , the risk of recurrence will be high . She can use HRT after surgery to protect her bones from developing osteoporosis . On the other hand HRT may increase the chances of cardiovascular disease or cancer breast although this is not proven for premature menopause . Trying to reserve part of the ovary or to save eggs is not applicable now . She will be given written information and addresses of support groups . I will inform her about the ongoing clinical trials for ovarian cancer .
I will do FBC ,LFT , urea & electrolytes .Tumour markers CA125 to calculate RMI ( u/s criteria multip ca125 multip 1) and CEA will be done . Abdominal u/s and CT abdomen nd pelvis will be done to discover ascites or liver or other organ metastasis and to examine any lymph node enlargement . IVP will be done to see the ureter and its relation to the mass .
b)Surgical treatment is the cornerstone for management of ovarian cancer . Primary debulking surgery for stage 1 and 2 with aim of cure will include removal of the tumour , total hysterectomy ,bilateral salpingooopharectomy , infracolic omentectomy and peritoneal wash for cytology . It includes also tissue biopsy from the under surface of the diaphragm and pelvic & paraortic lymph node biopsies .The prognosis is best if the operation is done by gynecological oncologist in a multidisciplinary center .
Fertility reserving surgery done in young women as cystectomy or oopharectomy (less than 40 ) for stage 1 disease have a recurrence rate of about 9% .
In advanced disease where traement is palliative (stage 3& 4) debulking surgery aims to reduce the residual tumour mass to less than 2 cm . Interval debulking surgery could be done if response to chemotherapy as judged by imaging and CA125 is not optimum . The effect of this surgery on survival is uncertain .
Surgery has a role in recurrent disease .Secondary debulking surgery may be done . However this must balanced against morbidties like bowel obstruction and adhesions and ending with colostomy and quality of life of the patient .



Posted by Shalini  M.
Sha
a)I would begin by asking about her symptoms-whether she has dyspepsia,associated unexplained weight loss,loss of appetite,abdominal bloatedness,bowel symptoms like constipation,blood loss with stools to suspect endometriosis..Also I will ask about her menstrual cycles-their frequency,duration and amount of bleeding.Any history of dyspareunia should be asked about.Her present contraceptive in use should be noted as any COC useage reduces the risk of ovarian cancer.Any past history of PID should be asked.Any family history of breast,ovarian ,endometrial cancers should be asked to enable screening for genetic cancer syndromes like BRCA 1,2,HPNCC.Also her cervical smear history should be asked .On examination her BMI should be calculated .On abdominal examination,any lump or ascites should be noted as also any tenderness.On vaginal examination uterine size,tenderness,fixity should be noted as also the size,consistency of ovarian cyst and its fixity and fullness and nodularity in the pouch of douglas.This lady will be very anxious about this finding and allaying her anxiety is important.She should be sympathetically and reassuringly explained that this cyst needs further evaluation to conclude at it\'s final diagnosis and CA-125 needs to be assessed in the blood as also a detailed abdominal or vaginal scan to see for multinodularity,bilaterality,ascites,solid areas and any evidence of metastasis to calculate the ultrasound score which would enable us to calculate a risk of malignancy index.A CA-125 less than 30IU/ml is normal although elevated levels can be suggestive of endometriosis,malignancy (it is elevated in 80% ovarian cancers.)MRI is non-invasive and helpful to study the type of ovarian cyst and extent of spread in case of malignancy.She should be explained that on the basis of her RMIscore her probability of having a malignancy can be assessed and necessary treatment planned.
c)Surgical management in ovarian cancers are curative aand aid in diagnosis as also palliative.A staging laprotomy helps to estimate the extent of spread asalso the need for adjuvant therapy.Also if fertility conservation is important then conservative surgeries like cystectomy can be planned if one is reasonably sure other ovary is not involved.However there is a need for continous surveillance after conservative surgeries as there is a risk of malignancy that was missed in contralateral ovary.Also cytoreductive surgeries can be done to reduce the size of disease for which chemotherapy has to be given to improve it\'s sensitivity.However sometimes it can be difficult to debulk fully the disease as morbidity of surgery would be very high.Palliative surgeries like colostomies,urinary diversions are necessary to improve the quality of life in end stage malignancies where suffering needs to be reduced.There is risk of anaesthesia in such morbid patients and pain relief is another difficulty.
Posted by shipra K.
shipra
A)Detailed history should be taken regarding associated features of distention of abdomen(which could be because of the mass or associated ascites),any urinary complaints(which could be a part of pressure symptoms ),bowel complaints like constipation ,bloody diarrhea, history of alternate constipation and diarrhea(in case primary tumor from the bowel).History of loss of appetite ,loss of weight(symptoms of malignancy).
Detailed menstrual history including age of menarche,her menstrual cycles,any recent abnormality in her menstrual cycle(menorrhagia because of granulosa cell tumor,ammenorrhoea could because of androgenising tumor).
Any history of infertility treatment .If patient of asian ethinicity then history of tuberculosis.
Past history of breast cancer., any medical disorders as she is likely to undergo surgery.
Family history of breast ,ovarian, colorectal or any other cancers in the family.
Examination would include general examination specially looking for any palpable lymph nodes, respiratory system for any pleural effusion,per abdominal examination to see for any distention,size ,site,consistency,surface( regular or irregular),mobility of tumor.A per speculum to see any abnormality in the cervix or vagina and bimanual examination for size of uterus and confirm the findings of abdominal examination regarding the adenexal mass.
Investigations include FBC,urea and electrolytes,liver function test,chest X-ray,ultrasound whole abdomen,CA125,CEA. MRI can be done.
Counseling would include telling her 10% of premenopausal ovarian tumors are cancerous,and chances are higher if she has family history of breast or ovarian tumors.Risk of malignancy index can be used in telling her the chances of it being malignant.If more than >250 there is a75% chance of it being malignant.She would require surgical removal of the tumor either by laparatomy or laparoscopy.And if risk of malignancy index high(>250) she would have to be referred to a oncology centre for treatment.
B)Surgery is the main stay of treatment for carcinoma ovary.For early stage disease Total abdominal hysterectomy with bilateral salpingoopherectomy with full staging laparotomy (which includes cytology samples frm peritoneal fluid , scrapings from undersurface of diaphragm ,omentectomy )would be only treatment required For late stages primary debulking would remove bulk of tumour and better chances of survival with chemotherapy thereafter.A Residual tumor of less than 5 mm was associated with a median survival of 40 months. With chances of survival falling sharply with the increasing size of residual tumor. Interval debulking is also being studied which is done after six cycles of chemotherapy(neo adjuvant chemotherapy) with good results.
Limitations of surgery include needs oncologist surgeon to do ovarian cancer surgery.Most ovarian cancer are detected at a late stage and therefore are widespread tumors which make the surgery extremely difficult and complete resection of the tumor might not be possible.Another limitation is that laparoscopy(with its inherent advantages ) is not preferred for cancer ovary Though its role is being studied.
Posted by SUNDAY A.
SOS answers

The initial assessment would involve a detail history on the onset of pain, nature-stabbing or dull, aggravating of relieving factors, associated GI symptoms such as vomitting, nausea, diarrhoea or constiaption. Associated abdominal swelling and progression of swelling would be relevant with history of weight loss, loss of appetite and generalised malaise. History of pedal or generalised oedema, chest pain or shortness of breath should be asked. Family history of cancer-ovarian/endometrial/cervical should be asked as well as cervical smear history, use of ovulation inducing drugs such as clomide or any fertility treatment. Alcohol intake as well as smoking and use of recreation drugs should be assessed.
Relevant physical examination would include vital signs such as the pulse rate, BP, cardiovascular examination for the heart sounds and presence of murmur and Abdominal examination to exclude hepatosplenomegaly and ascites. Pelvic examination may be done to exclude any vulva, vaginal, cervical and uterine pathology . Further investiagation would include FBC, U/Es, LFT, Coagulation profile, urgent Ca-125 to calculate the risk of malignacy index (RMI) and a referal to the local Gynaecology MDT would be made. I would tell the patient that there is a possibility of ovarian cancer but more test needs to be done which may include MRI/CT scan and referral to a cancer centre may be necessary. I would also inform that definitive operation or treatment may impact negatively on her desire for pregnacy in the future and options such as ovarian/oocyte preservation or donation in the setting of IVF, adoption or surrogacy might be the possible option depending on the diagnosis. I would discuss this in a sensitive and reassuring manner bearing in mind that she would be anxious and the plan of management documented in the notes.

b) Surgical treatment of ovarian cancer would involve early stage- 1a/b ovarian cancer. Later stage would require additional treatment such as chemotherapy or radiotherapy as the main treatment or as adjuvant therapy. The limitation of surgery arises from the fact that majority of patient with ovarian cancer do not present early and majority of patient are seen with stage 3 ovarian cancer when the 5 yr survival is less than 30-40%. The lack of suitable marker or monitoring for ovarian cancer also contributes to this problem as well as lack of definite symptoms or signs which women can watch out for which may predict ovarian cancer.
Posted by G. K.
a)
Initail assessment should entail queries regarding other symptoms in addition to the ones mentioned above.This would include associated symptoms of any recent weight loss judging by the recent change in the size of clothing. Associated loss of appetite, early repletion or nausea or vomiting should be inquired about, since these features can be present in ovarian cancer.
Also inquire about pressure symptoms e like frequency of micturition or urinary retention,or bowel symptoms like constipation.
Inquire about past history of ovarian cysts, and any treatment for those such as laparoscopic oophorectomy or laparotomy.
Inquire about any history of endometriosis since an andometrioma can also present as a complex ovarian cyst on ultrasound.
Inquire about family history of ovarian cancer/breast cancer in first degree relatives. Since known carriers of BRCA1 and BRAC2 gene mutation or a known history of type 2 Lynch syndrome will make the suspicion of ovarian cancer highly likely.
Inquire about patents wishes regarding preservation of fertility/desire to have children.
Inquire about menarche, any recen tchange in regularity of menstrual cycle since ganulosa cell tumours can be associated with irregular periods.
Other u/s features of cyst should be reviewed since the presence of solid areas,multilocular cyst,evidence of ascites or metastases will make the cyst highly suspicious in nature.
Blood test should be taken for CA 125 and other serum markers such as CEA, Ca19.9 which are raised in epithelial ovarian neoplasms.Other serum markers for non epithelial tumours should also be checked such as alpha fetoprotein(raised in endodermal sins tumour) LDH(raised in dysgerminoma), and inhibin a (raised in Granulosa cell tumours).Blood for baseline investigations suchas FBC, LFTS and Uansd Es should also bedone.
Ca125 should be used be used to calculate risk of malignancy index(RMI).Depending on the RMI the patient will be councelled accordingly.She should have a chest x-ray to look for any matastases tothe lungs. She will need a CT pelvis to look for any local extension and involvement of pelvic and para aortic lymph nodes.
If RMI is less than 20, the patient should be told that her risk of developing cancer is about 3% which is quite low and her mangement will be in a general gynae unit. If RMI is between 20 and 250 her risk of cancer is about 20% she will be referred to a cancer unit for further management.If her RMI is aboce 250, her risk of cancer is >70% and her management will be undertaken by a gynaecoloigcal oncologist with input from a medical oncologist if necessary.Incase of advanced cancer she will need surgery which might entail removal of uterus and ovaries which may render her infertile.She should be provided with written information.
b)
The role of surgery in treatment of ovarian cancer can be for the purpose of surgical staging to determine the extent of the disease.It involves TAH,BSO, infracolic omenectomy, scrapings from the under surface of the diaphragm and biopsy of any suspicious lesions.It can be curative depending on the tumour grade and extent of spread. If the disease is extensive, it can be for the purpose of reducing the tumour burden by debulking as much tumour tisue as possible and pave the way for chemotherapy.
It\'s limitations include incomplete resection of tumour since microscopic disease can not be seen.In advanced disease surgery is not curative.It will lead to loss of fertilityif uterus and both ovaries are removed.The risks of injury to bowel necessitiating a colostomy, bladder injury,ureretic injury, bleeding necessitating blood transfusion,post operative pain and venous thromboembolism are associaetd with surgery.
Posted by SANCHU R.
A healthy 37 year old nulliparous woman has been referred to the gynaecology clinic with a 6 months history of vague abdominal discomfort and an ultrasound scan showing a 10cm complex right ovarian cyst. (a) Discuss your initial assessment including how you would counsel the patient [12 marks]. (b) Discuss the role and limitations of surgical treatment for ovarian cancer [8 marks].
A)The patient would be asked for symptoms of loss of appetite, loss of weight indicating malignancy, urinary and bowel symptoms which may be due to pressure or spread of cancer to bladder or bowel. Bowel symptoms can also indicate primary GI malignancy with ovarian secondaries. Dyspnea, tachypnea would indicate pleural effusion or lung metastasis.
Her menstrual history should be obtained. Presence of severe dysmenorrhea may suggest endometriosis, the cyst being an endometriotic cyst. A hormone-secreting tumour may present with amenorrhea or irregular bleeding. Virilising symptoms should be asked for.
History of dysparaeunia suggests endometriosis.
Past gynacological history for endometriosis should be obtained.
Her fertility issues should be explored. Ovulation induction is associated with ovarian cancer.
Her contraception if any should be noted. Combined Oral contraceptives are protective against ovarian cancer.
Any family history of breast cancer, ovarian cancer or colon cancer should be asked for since BRCA and Hereditary Non-Polyposis Cancer of Colon run in families.
General examination is done for presence of malignant cachexia and lymphadenopathy- subclavicular and inguinal. Examination of the chest for pleural effusion is done.
Abdomen should be examined to determine the size and consistency of the mass, presence of any other mass indicating GI malignancy, for liver involvement, ascites,. Bimanual examination is done to confirm the findings. The presence of fixed retroverted uterus or uterosacral nodules may suggest endometriosis.
Investigations would include Tumour markers- CA-125, AFP, HCG, LDH. CA 125 although not very specific, is elevated in epithelial ovarian cancer. AFP is high in yolk sac tumours and HCG in choriocarcinoma . LDH is also high in ovarian cancer. In addition to diagnostic value, tumour markers serve as baseline for further management.
CT-Abdomen & Pelvis with contrast to note the size, consistency and origin of the mass, involvement of adjacent structures, metastasis and for involvement of lymph nodes.
The patient should be counselled regarding the risk of the ovarian cyst being malignant because of the size and complexity of the mass. But the patient being young, a complex mass can be totally benign like an endometrioma or a dermoid cyst.
If there is no evidence of spread of disease or involvement of the other ovary by imaging, she can be counselled and consented for laparoscopic salphingo-oopherectomy with staging by an oncologist. Depending on the histology report and findings on laparoscopy, further management would be planned, so that her fertility is preserved.
A malignant ovarian cyst in a young woman has a high chance of being a germ cell tumour for which fertility preserving surgery is possible.
A CT-guided biopsy can be done. If she has an epithelial cancer with evidence of spread she will be counselled for staging laparotomy with TAH & BSO .
She must be counselled about the prognosis and the need of chemotherapy if malignancy is diagnosed.

b)Surgery forms the mainstay of treatment for ovarian cancer at any stage. For stage 1a in a woman wanting to preserve her fertility, salphingooopherectomy is done. All other stages require Staging laparotomy, total abdominal hysterectomy and bilateral salghingo-oopherectomy with infracolic omentectomy .
Chemotherapy is needed since surgery cannot completely eradicate disease which spreads primarily to the peritoneum.
In advanced cancer, debulking is done to improve the response to chemotherapy. If inoperable, interval debulking is done after 3 cycles of chemotherapy.
For germcell tumours in a young woman, removal of the ovary followed by chemotherapy can be done since they respond very well to chemotherapy.
Posted by robina K.
(A) Aim of assesment is to differentiate malignant ovarian tumours from benign ovarian masses like endometrioma and dermoid cysts. Sonographic findings should be explained to the women and a need for further investigations should be discussed.I will tell her that in majority of young women the cysts are benign and in 1-2% it could be malignant.This is going to arise severe anxiety therefore a sensitive and supportive approach should be adopted.Her partner or a relative should be invited to accompany her if she wishes to .
I will ask the women about the symptoms suggesting of malignancy like abdominal distention, anorexia, weight loss.Symptoms of secondaries like SOB, Hematuria or rectal bleeding . A personal history of breast cancer or family history of ovarian cancer in first degree relative significantly increases the risk of ovarian cancer .History of other cancers in the family like endometrial or colon cancer also increases the risk . I will ask about her menstrual cycle, regularity, amount of bleeding, intermenstrual bleeding, LMP, postcoital bleeding and smear report . I will inquire about infertility and its treatment as ovarian stimulating drugs are associated with cysts as well as epithelial cancer if used for a along period .History is obtained about recent contraception and wishes of future pregnancy. Infertility, dysmenorrhoea and deep dysparunea indicates endometrioma and endometriosis .
I will check her B.P, BMI. I will palpate for inguinal and supraclavicular lymphnodes . An abdominal examination is carried out for ascites(shifting dullness and fluid thrill), cyst size, nodularity, mobility and bilaterality .A pelvic examination for uterine size ,mobility and its relationship to the cyst .
I will score her risk of malignancy index (RMI) from ultrasound findings of unilateral or bilateral , multilocular, solid areas, ascites and presence of metastasis multiplied by 1 for her premenopausal age and ca125 level of more than 30 IU /ml .A score of less than 25 has a risk of malignancy of less than 3%. A score of 25-250 is intermediate risk with a malignancy risk of 20%. A score of more than 250 is high risk and carries 70% risk of malignancy .
I will counsel the women about the definite removal of the cyst via laparotomy or laparoscopicaly and the place of operation will depend on RMI. If she is low risk she will be operated by a general gyaecologist. if risk is intermediate she will be operated in a cancer unit while a high risk score needs a full staging laparotomy in a cancer centre in a MTD context .A high RMI score needs immediate referrel.

(B) Surgery in the form of a laparotomy is advised for staging which determines prognosis and further need of adjuvent chemotherapy .Laparotomy is perf ormed by a midline incision,ascitic fluid or peritoneal washing is obtained for cytology.In early stage disease fertility preserving surgery is possible as unilateral oophorectomy after frozen sections ,however there are risks associated with major surgery and anesthesia.For sraging and prognosis imaging like CT, MRI and doppler may be used. Surgery provides tissue for histology .
Surgery can be curative in stage 1c, stage 2 and stage 3 by performing TAH+BSO,Infracolic omentectomy +/- pelvic and para aortic lymphadenectomy . In stage 3 or 4 debulking surgery is performed to remove all the malignant tissue and not more than 2 cm.However debulking surgery may not effect the prognosis even after chemotherapy .Some oncologists may advise neoadjuvent chemotherapy and interval laparotomy in that case primary debulking surgery may not be feasibile .
Second look laparotomy carries risk and is not advised . Surgery can be used as a palliative if colostomy is needed for acute intestinal obstruction .
In stage 1a or 1b laparoscopic oophorectomy may be performed along with biopsy of the other ovary,peritoneum and peritoneal washings, however it needs expertise, equipment. With conservative surgery primary peritoneal cancer cannot be prevented .
Posted by Ron C.
RnRn

A.
Her anxiety regarding scan finding must be acknowledged and approached woth empathy. A positive family history for ovarian cancer, especially in 1st degree relatives, doubles her back ground risk of 1.4% life-time, and if BRCA1 or BRCA2 is involved much higher even. Other sinister signs are loss of weight & appetite with increasing abdominal distension, dyspnea, change in pattern of bowel-openings, symptoms of obstruction or difficulty passing stools or urine. A history of cycle-related and menstrual pain could point to endometriosis / endometrioma as possible cause. A history positive for sexual transmittable disease (STD) and/or unprotected sex with multiple partners, vaginal discharge, could point to possibility of chronic pelvic inflammatory disease (PID) with tubo-ovarian abcess.
Examination of blood pressure & pulse rate as part of pre-operative assessment. Temperature for fever. Palpation of the abdomen to determine mobility of mass, percussion to look for ascites and auscultation to assess bowel sounds. Chest auscultation to identify presence of pleural effusion. Supraclavicular palpation to look for enlarged lymphe nodes. On speculum examination cervical discharge may be noted, triple swabs are taken. Vaginal examionation can assess relation of mass to uterus, mobility, presence of retroverted uterus, fixed cervix and excitation and maybe endometriosis nodules.
Full blood count may show raised white blood cells, CRP may be raised, CA125 can be used to calculate risk of malignancy index (RMI). CT-scan of pelvis, abdomen & chest to look for metastasis.
She must be counseled that depending on RMI she probably has at least intermediate or even high risk for malignancy (ie 1:5 resp. 3:4) and that though the cyst may turn out to be benign, this will only be known after adequate histopathological examination, hence surgery is advised. This would involve midline laparotomy with total hysterectomy & bilateral salpingo-ovariectomy, washings & omentectomy if intra-operative findings are clearly malignant. Fertility-sparing surgery by only removing the affected ovary is only possible in benign looking disease or in borderline tumours with intact capsule, after confirmation by frozen section.

B.
Surgery involves midline laparotomy, washings for cytology, total hysterectomy & bilateral salpingo-ovariectomy, omentectomy and biopsies from suspicious nodes. Aim of surgery in early stage disease is to achieve cure by means of completely removing all tumour growth. If there is further involvement of tubes and uterus, complete clearance may not be possible, and role of surgery is to remove as much tumour as possible, aiming to leave not more than 5 mm tumour anywhere behind. This will improve response to adjuvant chemo and chances for survival. In more advanced disease with for example invasion of bowel, aim is still focused on removing as much tumour tissue as possible, but obviously chances for survival are much reduced. The surgery however will reduce symptoms like obstruction due to bowel invasion or hydronephrosis due to compression/tumour, and as such improve their quality of life as they will have a longer symptom free interval until recurrence. In stage 4 disease with distant metasis, role for surgery is rather limited. Treatment with chemo is palliative, and only if yields a good response and significant disease free interval is expected, interval debulking may be considered to relieve symptoms such as obstruction and get more yield form further chemo.
Posted by M E.
ME
a) I would assess the characteristics of her abdominal pain and relation to her menstrual cycle. Other associated symptoms, such as abdominal distension, since rapid distension secondary to a mass or ascites is more likely to be a malignancy. Pressure symptoms associated with the urinary tract. GI symptoms, such as vomiting and loss of appetite, unexplained changes in bowel movements may be associated with malignancy. Current history of smoking increases the risk of mucinous type ovarian ca.
Age of menarche before 12years is associated with a higher risk of ovarian ca. Changes in menstrual cycle and associated menopausal symptoms to rule out premature menopause. Any history of mennorhagia since this maybe due to granulosa cell. Dysmennorhea and dyspareunia can be associated with an endometrioma.
Previous history of ovarian cysts, the management offered and the histology from previous surgery would help in daignosing a recurrent cyst. Reason for infertility, if present and usage of Clomid for greater than a year is associated with increased risk of ovarian ca. Previous usage of the COCP, has a protective effect for ovarian ca. History of PID or STD to rule out a tuboovarian abscess.
Previous history of breast cancer and treatment and family history of breast, ovarian and colon ca are risk factors for ovarian ca.
On general examination, check BMI, BMI > 30 associated with increased risk for ovarian ca. Conversely cachexia and palpable lymph nodes is assocaited with advanced stage. Abdomen, for shifting dullness or fluid thrill, since ascites is an indication for surgery. To determine if pelvic mass is mobile, since mobility assocaited with benign tumours. Speculum examination to asssess the cervix for any lesions. Bimanual exam to assess size, mobility, tenderness of mass. Respiratory examination to check for pleural effusion.
Investigations would included CBC, to check for anaemia or raised WBC with tuboovarian abscess. U&E and LFT for preoperative assessment. Ca125 has a 80% sesitivity and specificity for detecting epithelial ovarian ca. However it may not be reaise in 50% of stage 1 disease. Other tumour marjers such as CEA or CA 19-9 for mucinous epithelial tumours. CXR to assess and mets to the lungs. AN MRI may be required.
She should be counselled that only 10% of ovarian cyst in premenopausal patients are malignant. Her risk of malignancy index is calculated if < 20 there is a minimal risk of cyst being malignant. If >250 there is a 75% chance of malignancy and she would be referred to the gynaeoncologist for further management. her Ca125 alone cannot be used to determine what type of surgery she would require since it can be raised in many benign conitions which cause inflammation to the peritoneum, such as endometriosis.
Since her cyst is greater than 10 cm it is advisable for it to be removed. The typre of surgery performed would be based on her future pregnancy desires and her RMI. If her RMI is low and she wishes to preserve her fertility a cystectomy+/_ oophorectomy is offered to her. Complications of laparotomy are explained including bleeding, damage to urinary tract and bowel. Histology from the surgery would also determine if any further surgery is required. If malignant a total abdominal hysterectomy, left salpingoophorectomy and infracolic omentectomy maybe required after evaluation by the gynaeoncologist. If histology is normal, she should be reassured that having one ovary is sufficent for hormonal production and reproductive functioning.

b.Surgery allows a definitive diagnosis of ovarian ca to be made from a tissue specimen. Removal of large ovarian cyst or drainage of ascites allow relief of pressure symptoms. In early ovarian ca surgery may be curative. Staging can be performed at the time of surgery so planning for adjuvant management and prognosis can be determined. Second look surgery can be used for the diagnosis of persistant ovarian ca and it allows tumour resection.
Surgery for ovarian ca should be performed via a laparotomy as opposed to a laproscopic approach,since this carries an increased risk of tumour spillage and disemnation of the disease.
Most cases of ovarian ca present in the advanced stages. Perfoming surgery on patients with advanced stage ca will delay starting chemotherapy, since surgery is not curative in these patients.
Second look surgery is contraversial, since it does not improve survival rates in these patients.
Surgery in ovarian cancer patiets are associated with higher rates if intraoperative and post operative complications eg. increased risk of thromboembolism and infection.
Posted by M E.
ME
a) I would assess the characteristics of her abdominal pain and relation to her menstrual cycle. Other associated symptoms, such as abdominal distension, since rapid distension secondary to a mass or ascites is more likely to be a malignancy. Pressure symptoms associated with the urinary tract. GI symptoms, such as vomiting and loss of appetite, unexplained changes in bowel movements may be associated with malignancy. Current history of smoking increases the risk of mucinous type ovarian ca.
Age of menarche before 12years is associated with a higher risk of ovarian ca. Changes in menstrual cycle and associated menopausal symptoms to rule out premature menopause. Any history of mennorhagia since this maybe due to granulosa cell. Dysmennorhea and dyspareunia can be associated with an endometrioma.
Previous history of ovarian cysts, the management offered and the histology from previous surgery would help in daignosing a recurrent cyst. Reason for infertility, if present and usage of Clomid for greater than a year is associated with increased risk of ovarian ca. Previous usage of the COCP, has a protective effect for ovarian ca. History of PID or STD to rule out a tuboovarian abscess.
Previous history of breast cancer and treatment and family history of breast, ovarian and colon ca are risk factors for ovarian ca.
On general examination, check BMI, BMI > 30 associated with increased risk for ovarian ca. Conversely cachexia and palpable lymph nodes is assocaited with advanced stage. Abdomen, for shifting dullness or fluid thrill, since ascites is an indication for surgery. To determine if pelvic mass is mobile, since mobility assocaited with benign tumours. Speculum examination to asssess the cervix for any lesions. Bimanual exam to assess size, mobility, tenderness of mass. Respiratory examination to check for pleural effusion.
Investigations would included CBC, to check for anaemia or raised WBC with tuboovarian abscess. U&E and LFT for preoperative assessment. Ca125 has a 80% sesitivity and specificity for detecting epithelial ovarian ca. However it may not be reaise in 50% of stage 1 disease. Other tumour marjers such as CEA or CA 19-9 for mucinous epithelial tumours. CXR to assess and mets to the lungs. AN MRI may be required.
She should be counselled that only 10% of ovarian cyst in premenopausal patients are malignant. Her risk of malignancy index is calculated if < 20 there is a minimal risk of cyst being malignant. If >250 there is a 75% chance of malignancy and she would be referred to the gynaeoncologist for further management. her Ca125 alone cannot be used to determine what type of surgery she would require since it can be raised in many benign conitions which cause inflammation to the peritoneum, such as endometriosis.
Since her cyst is greater than 10 cm it is advisable for it to be removed. The typre of surgery performed would be based on her future pregnancy desires and her RMI. If her RMI is low and she wishes to preserve her fertility a cystectomy+/_ oophorectomy is offered to her. Complications of laparotomy are explained including bleeding, damage to urinary tract and bowel. Histology from the surgery would also determine if any further surgery is required. If malignant a total abdominal hysterectomy, left salpingoophorectomy and infracolic omentectomy maybe required after evaluation by the gynaeoncologist. If histology is normal, she should be reassured that having one ovary is sufficent for hormonal production and reproductive functioning.

b.Surgery allows a definitive diagnosis of ovarian ca to be made from a tissue specimen. Removal of large ovarian cyst or drainage of ascites allow relief of pressure symptoms. In early ovarian ca surgery may be curative. Staging can be performed at the time of surgery so planning for adjuvant management and prognosis can be determined. Second look surgery can be used for the diagnosis of persistant ovarian ca and it allows tumour resection.
Surgery for ovarian ca should be performed via a laparotomy as opposed to a laproscopic approach,since this carries an increased risk of tumour spillage and disemnation of the disease.
Most cases of ovarian ca present in the advanced stages. Perfoming surgery on patients with advanced stage ca will delay starting chemotherapy, since surgery is not curative in these patients.
Second look surgery is contraversial, since it does not improve survival rates in these patients.
Surgery in ovarian cancer patiets are associated with higher rates if intraoperative and post operative complications eg. increased risk of thromboembolism and infection.
Posted by Dr Saritha M.
A)
A detailed history about associated bladder symptoms like increased frequency and incomplete emptying, bowel symptoms like constipation is asked. History of loss of weight, decreased apetite, and dyspeptic symptoms are enquired. Menstrual history about cycle regularity and excess blood loss is enquired. Contraceptive history is enquired. Family history of ovarian malignancy and breast cancer is enquired. Previous history of breast cancer is also enquired.
On examination, BMI is checked. Breast examination is done. Abdomen examination is done checking for mass palpable and its features about approximate size, tenderness, mobillity, consistency,evidence of free fluid. Bimanual examination involves uterine position and mobility, adnexal mass tenderness,size, mobility and opposite adnexa is checked.Per rectal examination for recto vaginal septum is done.
Investigation includes: Full blood count, Blood urea and serum creatinine, liver function test. Ultrasound may be coupled colour doppler for pulsatily index and Resistivity index of value 0.4-0.8 indicates malignancy.but not considerd superior to grey scale trans vaginal ultrasound. CT scan is for the extent of metastasis and to know the resectabillity. MRI is also helpful but not done routinely.
Serum markers like CA-125 for epithelial ovarian cancer though not specific to ovarian cancer, levels are useful to caclucate risk of malignancy and follow up.other markers of help Lactate dehydrogenase, CA-19-9, for other ovarian tumors.
It increases anxiety of the women and hence sensitive counselling involves to expalin the ultrasound findings possibily of ovarian malignancy but only confirmed following histological diagnosis , and surgical staging. If it is early stage fertility preserving surgery will be carried out and will not affect her fertilty and will have good prognosis.
B)
Surgery is the definitive treatment. It involves surgical staging. It involves a systemic exploration of peritoneal surfaces.Ascitic fluid sampling, peritoneal washings, extent of tumour invovement for opposite ovary and the uterus. Diaphragmatic biopsies or under surface scrapings sampling of pelvic and para aortic lymphnodes.
If it is stage Ia, with the availability of frozen section of opposite ovary conservative surgery involving salphingo oophorectomy is carried out, requiring further regular follow up for screening.
If davanced staging then optimal primary cyto reductive surgery is carried out TAH -BSO with omentectomy and resection of the metastasis, and adjuvant chemo therpy is given. But needs follow up because of residual disease or recurrence.
Management is done with involvement of gynaec oncologist.
Posted by Leen K.
LEEN
A healthy 37 year old nulliparous woman has been referred to the gynaecology clinic with a 6 months history of vague abdominal discomfort and an ultrasound scan showing a 10cm complex right ovarian cyst.
(a) Discuss your initial assessment including how you would counsel the patient [12 marks].

I would obtain a history from her and enquire about the nature of the pain, and whether there are any associated urinary symptoms such as frequency or urgency - as the cyst my be exerting pressure on the urinary tract/bladder. Associated bowel symtoms such as constipation or urgency should also be asked about. I would ask about associated bleeding (PV/PR) and weight loss or anorexia, which may suggest a possibility of malignancy. Shortness of breath or ascites may suggest metastasis of malignancy.
I would also want to ask about any family history of cancer - ovarian and breast in particula, but also of others such as bowel, lung, endometrial and so on. Iwould enquire whethere there are any known hereditary cancer syndromes in the personal and family history - such as BRCA1 or BRCA2; noting that women with these gene defects tend to present with ovarian cancer earlier (in their 30s) compared to the general population.
I would enquire about past and present contraception (combined oral contraceptives confer some protection against ovarian cancer), and previous gynaecological history including abdominal and pelvic surgery. I would also find out about her preproductive intentions.

I would check her BMI and blood pressure - obesity or hypertension may complicate management/treatment. I would also arrange for a CA125 (serum) and together with her ultrasound findings work out her RMI (risk of malignancy index) - I would arrange another ultrasound if the relevant details for RMI calculation has not been done/documented. Any complicating factors for surgery such as a large fibroid uterus may also be detected.
I would counsel her that if the RMI is low, ovarian cystectomy is usually the management (Conservative management runs the risk of ovarian cyst torsion or rupture, at this size); but if that is not possible (for example due to not enough ovarian tissue to salvage) an oophorectomy may need to be performed. She will also require a laparotomy as laparoscopy will not be suitable due to the size and nature of the cyst.



(b) Discuss the role and limitations of surgical treatment for ovarian cancer [8 marks].

In stage 1a or 1b of ovarian cancer, surgery has been shown to improve survival of the patient. However, if the capsule of the ovary has been breached, she will require adjuvant chemotherapy as well. In advanced stages, surgery alone does not significantly improve prognosis or survival. It however may be performed for symptomatic relief for the patient (for example if it is compressing the bowel or urinaty tract). Most ovarian cancer unfortunately are not diagnosed in stage 1, but are diagnosed in the more advanced stages, making surgery alone not the best treatment option.
Posted by Maayka ..
maayka

a) A history will be obtained, with particular reference to the presence of other symptoms of this cyst. It is important to determine if this is a malignant lesion or benign and to avoid possible complications like torsion or haemorrhage. Symptoms like urinary frequency, constipation will suggest pressure effects. Weight loss, early satiety, nausea and vomiting can suggest advanced ovarian cancer. Finding out about her risk factors for ovarian cancer such as early menarche, previous history of breast cancer or a family history of breast/ ovarian cancer will determine her likelihood. Prior fertility attempts with ovulation inducing agents and duration of use may have been a causative factor. The patient’s possible testing for BRCA1 gene if present makes her a likely case of ovarian cancer. It is necessary to determine her fertility wishes and the presence of co-morbidities as it will help in the treatment offered.
An examination will reveal if there is significant weight loss if she appeared cachexic and abdominal examination will determine if there is any evidence of clinical ascites and lymphadenopathy and tenderness over the probable mass arising from the pelvis.
Investigation will include blood investigatons – full blood count to rule out anaemia;urea and electrolytes and liver function tests - to have as baseline and ensure no likely metastases; CA125 levels to asses the possibility of a malignant lesion if very high. The ultrasound findings will be noted specifically for the consistency of the cyst- solid components, presence of ascites, and multiple cysts are not suitable for conservative management by observation. The RMI (risk of malignancy index) will be assessed and if deemed high she will be referred to a cancer centre for multidisciplinary and specialist care.
The patient will be told that a lesion of this nature, being complex and 10cm, should be removed because of the risk of malignancy. The type of surgery offered will be dependent on her RMI score. If likely malignant a total abdominal hysterectomy and bilateral sal pingoophorectomy (TAH+BSO) will be recommended with infracolic omentectomy. If likely a borderline tumour then it is possible to have unilateral oophorectomy done and histology confirmed before further treatment required. If ovarian cancer has been confirmed, adjuvant chemotherapy is usually offered unless the staging was FIGO stage 1a. The patient should be involved in the treatment plans.


b) Surgery for ovarian cancer aims to remove all malignant tissue, especially if early d disease, and if advanced to ideally remove all tissue and leave maximum of 2cm deposit. The TAH+BSO and infracolic omentectomy is accompanied by a lyphadenectomy. It is debatable whether this is beneficial because it increases the morbidity for the patient and not increase the prognosis significantly. Surgery for early disease can be curative for some and these patients do not require follow up chemotherapy. It is best t o perform debulking surgery before chemotherapy, because it reduces the amount of diseased tissue and better results with chemo. It allows proper surgical staging to be performed to adequately treat thereafter.
The limitation is that with optimal debulking it is impossible to determine if peritoneal deposits have been left behind and thereafter most patients will receive chemotherapy after. It increases the patient’s morbidity especially if bowel resection and lymphadenectomy is done. With these, it is not thought to improve survival significantly in the long term.


Posted by A H.
AH
a) I will take a detailed menstrual history wich will include the date of her last period and if if her cycles are regular and associated dysmenorrhoea can occur with endometriosis. Use and duration of use of the combined oral contraceptive pill will be asked as this reduces the risk of ovarian cancer. A history of infertility will be noted, and if relevant, the uce of ovulation inducing agents, in particular, clomiphene citrate which is associated with an increased risk of ovarian cancer.
A history of weight loss, malaise, nausea and vomiting will be asked because this is found in advanced ovarian cancer.
Family history of breast or ovarian cancer in first degree relatives less than 45 years, as well as endometrial, colon and pancreatic malignancy will be taken to assess her risk of having one of the hereditary cancer syndromes due to BRCA1,or BRCA2 gene mutation or the Lynch 1 or Lynch 2 syndrome.
A full general examination will be done looking for pallor, icterus, signs of weight loss and lymphadenopathy (cervical,supraclavicular, inguinal).
The chest will be examined for evidence of a pleural effusion.
An abdominal examination will be done to elicit tenderness, masses and ascites. A mass arising out of the pelvis as well as its size and mobility will be assessed. A fixed mass in the upper abdomen may be due to omental caking.
A pelvic examination will be done to assess the cervix, size ,tenderness and mobility of the uterus and/ or adnexal masses.
Blood investigations will include a full blood count for haemoglobin concentration, and platelets. Malignancy is associated with anaemia and this should be corrected prior to surgical intervention. Baseline renal function tests as well as liver funnction tests includidig serum proteins will be done. Tumour markers will be requsted. CA125will be done to rule out epithelial ovarian malignancy which can occur in young women with hereditary cancer syndromes. Alpha feto protein and carcinoembyogenic antigen will also be done. A chest Xray will be done to exclude pleural effusion and metastases. An abdominal ultrasound will be done to assess the liver (size and morphology) for evidence of metastases, as well as the renal tract looking for evidence of hydronephrosis.
Her risk of malignancy index (RMI) will be calculated based on menopausal status (premenopausal given a score of one,and post menopausal given 3) ultrasound features and the CA125 value. THis will guide referral for management;to a cancer center if high risk (RMI>250) a cancer unit if moderate risk (RMI of 25 to 250) or a general gynaecologist if low risk (RMI<25)
She will be told about the differential diagnoses and that her risk of malignancy wil be estimated from the historical findings and her RMI. She will be told that although only about 10 percent of ovarian malignancy is due to herditary syndromes,when it occurs in the younger age group it raises the risk. If she has a family history referral to a geneticist for pedigree analysis will be offered. Genetic studies using direct mutation analysis or linkage analysis.
She will be told that this is an autosomal dominant trait but may not manifest in all generations due to incomplete penetrance and a vast number of mutations. A negative result may not represent absence of risk.
b) The role of surgery is initially to fully stage the disease so that the patient and her relatives can be fully counselled on her prognosis and a plan of management can be made. Debulking of as much tumour as possible will improve her survival and disease free interval. The effectiveness of adjuvant chemotherapy is improved markedly if no or very little residual disease is left. The recommendation is less than 1.5 cm.

Surgery is also useful for palliation in advanced disease or secondary debulking if there is tumour recurrence. This will improve survival as well as quality of life. Surgery can be done to address complications like bowel obstruction or to relieve discomfort due to a large mass or ascites.
The limitations are that it may not be possible to debulk tumoour which is inaccessible,for example under the diaphragm or if there is entensive adhesions to bowelor bladder.
Surgery will not be possible if the patient is not fit for general anaesthesia or major surgery
Surgery requires highly skilled surgeons often as a part of a multidisciplinary team which can only be readily accessed at a cancer centre.
Posted by Nur Sakina K.
NSK

From A:
Ovarian cysts are a common finding in premenopausal woman. In most cases they are benign and are incidentally detected on ultrasound scan for other reasons. However, a complex cyst must be further investigated to assess the possibility of malignancy. This should be explained to the women in a sensitive manner as it can create anxiety.
Presence of any abdominal tenderness, site, nature and severity should be elicited. Its impact on her quality of life and the need for analgesia will identify the degree of bother to her. Other associated symptoms such as palpable mass, nausea, vomiting, pressure symptoms such as constipation, urinary retention/ hesitancy should be asked. Sinister symptoms such as weight loss, PR bleeding raises the possibility of malignancy being present.
A menstrual history including her LMP, regularity of cycle and irregular bleeding (postcoital bleeding/ intermenstrual bleeding), virilizing symptom helps assess possibility of a hormone-secreting ovarian cyst. Past surgical and gynaecological history of previous smears including abnormal smear, sexual activity including future fertility desires and current/ future contraception needs should be addressed as will affect the treatment options. Her expectations for treatment should be asked as will influence my management.
A family history of gynaecological cancers specifically: ovarian, endometrial and breast cancer suggests the presence of a familial cancer syndrome.
A baseline observation is obtained. Abdominal examination for tenderness: site and radiation, presence of rebound and guarding will suggests signs of peritonism. Any palpable mass should be assessed for mobility, size to identify routes of surgery if removal considered. A pelvic examination for tenderness and of any mass including site, mobility and size should be documented.
A full blood count (FBC) for hemoglobin level (anemia) and leucocytosis can be present in acute inflammation. Group and save is useful if surgery is considered. CA 125, CEA, CA 19.9 tumour markers help identify possibility of malignancy. A pelvic USS (TA and TVS) should be arranged to assess nature of the cyst and to calculate the risk malignancy index (RMI). Discussion regarding further management of the cyst will depend on the RMI calculated.

From B:
Surgery in ovarian cancer is for staging, diagnostic and curative reasons. Complete debulking surgery should be done by a gynae-oncologist in a cancer centre. A total abdominal hysterectomy (TAH) + bilateral salpingo-oophorectomy (BSO) , omentectomy, aspirations for cytology, examination of all intestinal and peritoneal surfaces with biopsy/ removal of any suspicious lymph nodes or lesion is done at primary surgery. The prognosis is best if minimal (< 1cm diameter) residual tumour is left after primary surgery.
In advanced disease, adjuvant chemotherapy is added to maximal primary cytoreductive surgery. In patient with co-morbid factors where extensive surgery is unsafe, chemotherapy can be used before radical surgery. However the evidence for its use is limited. Interval debulking surgery which involves operation after a short course of chemo (usually 3 cycles) in advanced disease has no survival benefit. Systemic lymphadenectomy is not done routinely as part of primary surgery for advanced cancer. It has no overall survival advantage.
Secondary debulking surgery has limited use, and is only considered where resectable disease is present, with an initial complete response to chemo with a long (> 12 months) treatment free interval.
However, there are risks of bowel, bladder, vascular injury and subsequent adhesion development with surgery. In young women, this results in loss of fertility and development of premature menopause. HRT is needed in these women. Alternatively, in young women with early stage (1A) ovarian cancer who wish to retain their fertility, oophorectomy of the affected ovary can be done.
Surgery may not be suitable for advanced metastatic ovarian cancer or in older women with medical conditions who are unfit for surgery.
Posted by Nur Sakina K.
paul,

sorry again!!i thought the dateline for the essays is every thurs and sunday (7 days)?? will u pls, please,please read my essay and comment. thanks.
Posted by R S.
Please if anyone interested in doing a combined study , my ID is ;

rasheed_70@yahoo.com

I\'m preparing for part 2 march 2010, looking to have a study partner.

thanks.
Posted by R S.
Please if anyone interested in doing a combined study , my ID is ;

rasheed_70@yahoo.com

I\'m preparing for part 2 march 2010, looking to have a study partner.

thanks.